prehospital airway management
TRANSCRIPT
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PREHOSPITAL AIRWAY MANAGEMENT
James Kempema MD FACEP
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DISCLOSURES
• None
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HISTORY
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LITERATURE REVIEW
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SUMMARY
• Worse outcomes in severe brain injured patients
• Worse outcomes in cardiac arrest
• Longer scene times
• Increased risk of aspiration
• Poor ventilatory management
• Exception:
• Higher trained providers (Air Medical) resulted in better outcomes
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BARRIERS TO SUCCESS
• Which patients are getting intubated?
• How much experience do the providers have?
• Access to induction medications and paralytics?
• What tools do you have for the procedure?
• Post-intubation management and monitoring
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TRAUMA INTUBATIONS
• Vast majority are severe head injuries
• Primary issues to AVOID in head injured patients:
• Hypoxia
• Hypotension
0
10
20
30
40
50
60
70
80
Mo
rtality
(%
)
Neither Hypoxia Hypotension Both
Any time
Arrival
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FACTORS IN EMERGENT INTUBATION SUCCESS
• Ability to adequately pre-oxygenate / Delayed sequence intubation
• Prevention of desaturation / passive oxygenation
• Techniques and tools
• Continuous confirmation of endotracheal placement
• Prevention of post-intubation hypotension
• Post-intubation management • Vent settings • Avoiding hyper- and hypoventilation
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CASE STUDY #1
• 72 yo female found obtunded
• Per family – PT feeling “ill” lately with elevated BS
• PMH: IDDM, HTN, CAD
• Exam: unresponsive, minimal movement to painful stimulus
• VS: P/112, 84/52, R/8, SpO2 84%, EtCO2 10, BS 442
• Does this patient need ventilatory support?
• What happens when she gets intubated?
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SHOCK INDEX
• Shock index = SBP / HR
• Normal 0.5 -0.7
• Shock index > 0.9 associated with post-ETI cardiac arrest
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CASE STUDY #2
• 23 yo female falls off cliff
• STAR Flight called for hoist rescue
• GCS 3, R/6
• How do you manage this patient’s ventilation while hoisting?
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CASE STUDY #3
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WHAT ABOUT ALTERNATIVE AIRWAYS?
• AKA: Blind insertion airways, supraglottic airways, extraglottic airway device
• Types: King LT, Combitube, I-Gel, LMA
• Most easy to place, reliable, some allow for gastric decompression
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• Bottom Line: BIAD had worse outcomes compared to ETI or BVM
• Limitations:
• Primary vs secondary device
• # of intubation attempts prior to placement
• Is it the device or the technique?
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CONCEPT OF RAPID SEQUENCE AIRWAY
• Use of sedation and / or paralytics to place an extraglottic airway as the primary airway
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RSA
• Extraglottic airways have evolved significantly in the last 10-15 years
• Easier placement, better glottic seal, ability for gastric decompression
• In simulated study – lower time to airway placement, less predicted hypoxic time
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WHERE DO WE GO FROM HERE?
• Indications for intubation:
• GCS < 8 = intubate!
• RR < 8 = intubate?
• Transport time / number and skill of providers
• Access to other options?
• Limit intubation to Advanced Providers
• Medications / tools / monitors to maximize success
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Thank you! [email protected]